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Listen in—the conversations we need to have about racism, health, and medicine

1st September 2017

Rebecca Cooney

North American Executive Editor for The Lancet | @BekRx

“In public health we view anything that affects people, the survival and well-being as a public health issue. It's obviously important to concern ourselves with the issue of white supremacy and that's what we saw on display in Charlottesville in a way that was shocking to many of us who, like myself, lived through and benefited from the civil rights era. This is a time for US physicians, healthcare workers, to really stand up and say that movements such as these will have an adverse population impact, and to use our professional standing to speak out against the enduring effects that racism has had on the health of our population, on the health of everyone.”

That’s Mary Bassett, Commissioner of the New York City Department of Health and Mental Hygiene, speaking about the events in Charlottesville this August 2017

Welcome to United States of Health Blog Podcast. I’m Rebecca Cooney North American Executive Editor of The Lancet. When we are confronted with brutal and graphic incidents—like Charlottesville—that hearken to our country’s painful history, they can be potent reminders that what we think of as remnants of injustice and inequality are very much alive, and it’s important for us to take time to reflect and process what lessons need to be learned or re-learned and what needs to change.

The medical profession takes as its primary credo, “First, do no harm.” The public health corollary to that as framed by the American Public Health Association says, “Public health promotes and protects the health of people and the communities where they live, learn, work and play.” Racism and discrimination aren’t vague concepts to be taken into consideration in some contexts of medicine and public health—they literally permeate the fabric of health in our country. And it’s critical that we begin to fundamentally incorporate the effects of racism and discrimination when we discuss health.

Throughout this podcast, we’ll be talking with doctors. Mostly women, mostly physicians, and mostly people of color. And we’ll be talking about racism at different levels of experience. Moving between interpersonal racism that is experienced by individuals to institutional racism to structural racism, that is the historically and culturally reinforced basis that underlies and reinforces belief systems, values, and discriminatory practices all of which produce adverse health outcomes. For some these are new concepts, for others, new names for experiences lived.

Tené T. Lewis is an Associate Professor in the Department of Epidemiology at Emory University who studies discrimination and health in African-Americans in the United States.

“I think now what's happening is the broader public is becoming aware of how many people really hold these sentiments, because I think as people we're so segregated and isolated from one another that we wind up socializing and interacting with people who are like us. If you're not a person who discriminates against people who hold those views, you are not socializing, you're not interacting with people. I think what happened with this last election and some of the rhetoric and a lot of the language that was being used, it kind of pushed it to the forefront and made more people realize like, "You know, this is actually still a problem in 2017, and something we need to start thinking more about."

Let’s start with the experience of physicians and health care providers of color—what happens when they themselves are confronted with racism or discrimination?

Nwando Olayiwola is the chief clinical transformation officer for Rubicon MD and an associate clinical professor in Family Medicine at the University of California, San Francisco. She’s written poignantly about the firsthand experience of dealing with a racist patient—the dynamics and feelings of being a black woman in a white coat.

“I think the experience that I had with this patient was so jolting because one, it didn't matter to him ... None of that mattered to him. It didn't matter to him that I was highly accomplished and I had chosen to be where I was and I was really there ... All that mattered to him was that he saw a black woman walk in and felt that in no possible way could this person be his doctor and take good care of him. So, on the one hand, it was extremely demoralizing because no matter how much I thought I had achieved and how well I think I had gotten towards my own personal goals, in one moment and in a very short encounter with a patient, all that could just be wiped away.

Esther Choo is an MD, MPH and an associate professor of emergency medicine at Oregon Health & Science University.

“Recently a patient and his wife asked me exactly what my Asian ethnicity was. And the way that it comes about usually is, ‘Where are you from?’ And I said that my background is Korean, and they kind of breathed a sigh of relief and said, ‘Well that's great because we would never be treated by a Vietnamese citizen.’

And I've had that happen before where they say, ‘We really had a bad experience with this type of physician.’ Or, ‘We would never be treated by those people again.’ And sometimes it feels directed against me very specifically or against Asians in general. But it is something that would not happen if you were not a person of color. No one would say, ‘Well I've been treated by a white physician before, so we don't accept white physicians anymore.’ They tend to be more toned down on the characteristics of that individual person.

So if you're a person of color, you often don't get to be an individual. You represent the entire group of those people. And all the assumptions they bring into the room with them.”

For many physicians and healthcare providers of color, encountering racism isn’t confined to interactions with patients. It can extend to colleagues, supervisors.

Jennifer Okwerekwu is a psychiatry resident at Cambridge Health Alliance and columnist for STAT news. She has also written on experiencing racism from patients but how little support there can be in that situation.

“As a woman, as an African American, as an immigrant, and as a medical trainee, my experiences of racism are not unique. They're certainly not unique to me, but the introduction of a power dynamic in the hierarchy of medical training is what makes a little bit more challenging to deal with. For example, as a medical student, when I had an experience where a patient called me a colored girl in front of an attending physician, from whom I was learning, and the attending physician didn't say anything to the patient when we were all together, the three of us in the room, nor did she say anything after the patient left when we were alone.

You can imagine the questions that kind of brought up for me. Does the patient respect me? Why are they not calling me by the name I introduced myself by? Why is the attending not introducing themselves? Does the attending think this way? Does the attending think I'm a colored girl? Did she just not notice? This happened multiple times within a clinic visit. I don't believe that she didn't notice. Maybe she just didn't know how to address it. In any case, it left me with a number of questions that I didn't really have any sort of productive outlet to ask them.”

Often it’s not the individual patients or colleagues that are the issue, but the setting, the institution itself.

As Dr. Olayiwola notes:

“Because we all know and I could bring together a room of black women physicians and we would probably all have very similar stories of times where we were looked down upon or we were…People didn't really necessarily think we were qualified to be there. We were passed over. Maybe we said something that was really intelligent and it was a surprise to people that that came from us. We were asked to do things that were not necessarily appropriate maybe on rounds, to bring breakfast or get someone a coffee when we were equal members of the team. I think we could all identify with that experience of that double jeopardy that we have.

For that, it's a lot harder because how do you instill the belief in an institution if there's institutional racism that's working against you, that there are policies and procedures that are actually going to not allow you to advance. If there's not sufficient support to recognize your unique needs as a woman or person of color in the academic institution or the academic hospital or the ranks of the system or professionally, you're maybe passed over for a promotion. You're not given the right mentoring to achieve tenure. You're not considered a leader.”

Dr. Choo notes how pervasive that sense may be.

“So people will say things about, ‘We're relieved you speak the English language so well.’ Or, ‘Do you believe in western as well as eastern medicine.’ I think there's still just kind of this constant stream of comments and questions and often it's just that people have never come into contact with anybody from my background or perhaps from a background other than their own. So some of them are just very naïve and it's hard to take offense. But it's certainly this background noise at some point of almost every day that I practice.

And so I do think when I talk to my friends who are of different backgrounds, especially right now my friends who are immigrants who are of non-Christian religions who have accents and were born out of the country, I know a lot of my friends are really struggling right now with overt racism. I think in many ways I don't see that and I don't encounter it to the extent that they are.

I think it is in general the reality of this country is the darker your skin is, the harder it is for you in healthcare.”

It seems that is a truism that extends beyond healthcare to encompass all of health.

But what do we know about the effects of racism and discrimination on health? Where it concerns black people in the US, actually a fair amount.

Here’s Dr. Lewis;

“What about all of these other things that happen in the African-American community, poverty, violence?, et cetera, et cetera, one of the things I think, I don't often say, but when you talk to African-Americans or black people, they don't think that it's an accident that they live in the worst communities or that they're exposed to the most violence. They don't think that these things have happened by chance. Studying something that's actually relevant to the community has mattered a lot for me as a researcher, particularly wanting to do work that's culturally sensitive.

One of the stressors that was consistently associated with health outcomes was discrimination, and what has been the most surprising thing for me initially was the consistency of the association, independent of again, all these things that we know happen to people, financial stress, negative life events. For whatever reason, discrimination seems to really matter for people, and so for me, that's the take home.

The outcomes that I've looked at are things like atherosclerosis or coronary artery calcification, visceral fat, which is the fat that surrounds your internal organs, mortality, which is a more obvious outcome, inflammation in the blood, and most of these are things that you don't know you have, so it's not as if people are sick and then going back and saying, ‘Oh, I think I got sick because I was discriminated against.’ It's actually, these are silent, so we can assume that there's really something going on.”

Epidemiology is an important way for us in a sense to discover and acknowledge the ways in which racism and discrimination have affected people of color in the US. But in addition to the necessity of descriptive data, there is also the strong need for the prescriptive. And targeting a new wave of physicians, researchers, and providers, those who are at the fore front of health may be one of the most substantial levers for change, for addressing racism and discrimination, and improving health.

Barron Lerner, is a physician, historian, and Professor of medicine and population health, as well as the Director of the Bioethics Curriculum at NYU.

“Bioethics is the study of right and wrong, in medicine in particular, so we're constantly addressing issues within medicine of trying to do the right thing, and issues of race come up not infrequently. There are lots of diseases and lots of situations in which race plays a role in medicine, and so part of what bioethics can add there is to add an ethical analysis to those sorts of issues.

When I read about the current issues surrounding, for example, the statues coming down, and the protests, there are lots of parallels within the world of medicine. I think the one that most people would think about is the Tuskegee study, which was an infamous study in which poor African Americans in the south were experimented on, and basically, their syphilis was let progress by the United States Public Health Service, and so when I teach bioethics, I ask the students to think about those questions historically. What was it that made a group of researchers who were otherwise, actually progressive, very focused on public health, very focused on their patients, what was it that allowed them, that made them do such an experiment that we find so heinous in retrospect? In trying to explore those answers, we understand racism more subtly.

It's no good, I think, to say, ‘Oh, those people were racist and we're not. That's why we don't do Tuskegee anymore.’ What's much more interesting is understanding the social factors that led this group of doctors to do an experiment that we would now call racist.”

It’s a forceful reminder of how even the well-intentioned within the medical establishment can make harmful decisions. We need to consider our blind spots, what actually constitutes racism, and to confront the biases that lead to decisions that we might not otherwise make if we were thinking from a different perspective or with a different lens. But importantly, we need to be willing to pull our statues down so to speak.

Dr. Bassett recalls how even unspoken details embedded in medical training can lead to misplaced assumptions and structural racism:

“When I think back to my own time as a medical student, I don't believe that there was anything in the curriculum that raised the question of race. There were many passive ways it was conveyed. For example, at DePaul in a class that we had about sexually transmitted infections, all of the photographs were [of brown colored genitals and that of course, reasonably, could lead people to the idea that most sexually transmitted infections were occurring among people of color. The issue of structural racism is especially important because a lot of the work that is currently affecting our curricula has to do with interpersonal racism.”

Here’s Dr. Choo on her perspective:

“I think that is just the tip of the iceberg in what we need to offer our trainees. I think we need to support them and make sure they know that they have the resources, but I think ultimately we need to be coaching our residents to expect it when they walk into the clinical setting, it will universally be there, and then know how to respond in the moment and then also know how do you walk away without this chipping away at your confidence and your morale. And your joy of being in medicine. And that's what I am hoping that we can move toward if this dialogue is to continue.”

Dr. Okwerekwu actually attended medical school in Charlottesville at the University of Virginia and after the violent protests there, wrote about her experiences. Not just about the kind of racism that gets on television—the torch-lit rallies, chants and violence, but of a different variety, what she calls the “quiet racism of every day” and she has advice for medical training going forward, and the importance of listening—really listening.

“I think this is a particularly salient question for the medical profession, because we train in learning to listen. Every day we listen to our patients. We listen to their hearts. We listen to their lungs. We listen, and we're able to formulate an understanding of that story, and take action on that story. We're very good at doing that when it comes to delivering medicine in the form of pharmaceuticals, or surgery, or whatever your intervention is. We need to apply those very same skills to listening to our colleagues, to listening to minorities in this country, because that experience might not be something that a lot of people have firsthand knowledge of.

When people like me are telling that story, people need to listen. People need to be willing to engage to a point of humility. When I do write these stories, I get people who write me back, people in the medical profession, people with medical degrees from all levels of training, telling me that, ‘Oh maybe it's not racism, or maybe it's not sexism, or 80% of people in Charlottesville voted for Hilary Clinton.’ Every time you try and justify the experience, I am telling you that I am having, you're not pushing the conversation forward, and you're undermining it.

I think applying those patient skills, those skills that we work so hard to perfect, and to learn to listen, and applying that to the humanity of both our patients and our colleagues, and the people of color, minorities in this country. Those stories are full of truth, and if your knee jerk reaction is to undermine that truth, then you're not listening.”

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Listen in—the conversations we need to have about racism, health, and medicine

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Rebecca Cooney discusses the new National Academies of Sciences, Engineering, and Medicine report on opioids with members of the committee